CLINICAL MEETING 11-1-2018 DEPARTMENT OF PEDIATRICS KIMS - - PowerPoint PPT Presentation

CLINICAL MEETING

11-1-2018

DEPARTMENT OF PEDIATRICS KIMS NARKETPALLY

Case Presentation by DR MOHAMMAD KAUSER 1st Year PG in Pediatrics

Chief complaints

• Informant : Mother
• 12 month old girl R/o Nalgonda, was brought with

complaints of

 Cold and cough -10 days  Fever - 9 days  Rapid breathing - 1 day  Not taking feeds -1 day

History of presenting illness :

• Child was apparently asymptomatic 10 days back

then developed -

• Cough was insidious, intermittent ,dry with no diurnal
• r postural variation.
• History of low grade fever, since 9 days, relieved on

medication, no diurnal variation.

• Child developed rapid breathing with no retractions.

• H/o refusal of feeds since 1 day
• No noisy breathing/nasal discharge/ear discharge
• No history of bluish discoloration of lips or peripheries
• There is no associated irritability/convulsions.
• No history of loose stools/ vomiting/ burning micturition/

abdominal distension

PAST HISTORY

• Baby had 8 episodes of cough and cold from the age
• f 20 days and was treated with oral medications.
• Child was admitted in hospital for LRTI and was treated

with IV medications for 5 days at the age of 2 months.

• Child was earlier treated by a family doctor, and has

come for the 1st time to our hospital

• No documentation of previous treatment/ admission in

hospital or discharge card was available

Family history :

• Product of 3 rd degree consanguineous marriage

(second child)

• No similar illness in the sibling or the family.
• No history of contact with tuberculosis
• Paternal Grand mother is a known Asthmatic

PEDIGREE CHART

5m deceased 3m sp 3m 12m renal agnesis abortion sp abortion

v v v v SB Dead 1 day

Antenatal history

 First trimester-  UPT confirmed at 2 months  No history of fever with rash  FA taken  Second trimester-  Foetal movements perceived from 5th month  2 doses of TT taken  Fe & Ca supplements taken  No h/o thyroid disorders/epileptic

disorders/hypertensive disorders/diabetes

 Natal history :

• Born through emergency LSCS. Indication being

Oligohydramnios

• Cried immediately after birth
• Birthweight - 2.6kgs.

 Third trimester-

• No h/o pre eclampsia, eclampsia/bleeding/leaking PV.
• No history of polyhydramnios
• H/o oligohydramnios in third trimester

 Postnatal history:

• Exclusive breast feeding started within 4 hrs and

continued till 6 months of life

• No postnatal problem. No history of neonatal ICU

Admission

 Immunisation history :

• Immunised till date as per National immunisation

schedule

• BCG scar seen on left arm.

• Developmental history:
• Child is able to walk with support, eat with spilling

with cup, can speak bi- syllables and plays peek a boo.

• Developmentally normal for age.
• Dietary history
• Observed intake 710 kcal, Expected calorie intake

900 kcal. Calorie Deficit 190kcal

• Observed intake of protein 12 gms Expected protein

18 gms,

 Socioeconomic history:

• Lives in pukka house.
• No overcrowding
• No pets.
• Separate kitchen with cooking gas present
• No exposure to smokers in the family
• Separate toilet facility present.
• They have safe drinking water source.
• Belongs to Upper middle socioeconomic class as per

modified Kuppuswami scale

SUMMARY OF HISTORY

• 12months female child a product of 3rd degree

consanguinity with

• Cold and cough 10 days,
• Fever for 9days,
• Rapid breathing from 1 day,
• Recurrent respiratory tract infections
• With family history of asthma

Based on the history ? Possibilities

Differential diagnosis based on history

1.

Foreign body aspiration - retention

2.

Repeated Aspiration with infection - GERD

3.

Cyanotic Congenital heart disease – repeated inf. with Left to right shunt

4.

Congenital lung malformations – Sequestered lung, CCAM, TOF- H

5.

Ciliary dyskinesias – Cystic fibrosis,

6.

Kartegener syndrome(situs inversus with immotile ciliary dyskinesia sunisitis )

7.

immmunodeficiency

8.

Tuberculosis

General examination

• Child is irritable. Afebrile
• No pallor/icterus.
• No cyanosis/clubbing/lymphadenopathy
• No oedema.
• Head to toe examination : Normal

Vital data

• Temperature 99 °F
• PR- 90/min, Normal in volume character and all

peripheral pulses felt.

• RR-48/min, Abdomino-thoracic type of respiration
• BP-90/60 mm of hg, in left arm with appropriate cuff

size in supine posture at heart level.

• Spo2 98% at room air

Anthropometry

• Acute malnutrition according to who classification

OBSERVED EXPECTED CENTILE

Weight 6.8 8.9 <3 Height 72 74 50 Head circumference 43.5 44.9 50

Respiratory System Examination

• INSPECTION
• Upper respiratory tract – normal
• Trachea appears to be deviated to right side
• Trail sign – sternomastoid prominence in the right side.
• Bony deformity over the right parasternal region
• Shape of chest- Right side parasternal bulge present.
• Chest movements appears to be decreased on the left

side.

• No engorged veins/No chest wall indrawing /retractions

Apical impulse not visualised. PALPATION – All inspectory findings are confirmed

• Trachea is deviated to right side
• Apex beat palpable in the right 5th intercostal space

lateral to right sternal border PERCUSSION –

• Resonant note on the left >> right.

AUSCULTATION:

• Bilateral air entry present but decreased in the left

inframammary area,left infra-axillary and infrascapular areas

• Extensive crepitations were heard throughout the lung

fields

Per abdomen

INSPECTION:

• Shape of the abdomen appears scaphoid.
• Symmetrical movements in all the quadrants with

respiration

• Umbilicus is central and inverted
• No visible masses and peristalsis

PALPATION:

• Soft
• Non tender
• No organomegaly

AUSCULTATION:

• Bowel sounds heard normal

Cardiovascular system examination:

 INSPECTION:

• Shape of chest- Asymmetrical, Right parasternal bulge

present

• No visible pulsations
• No engorged veins
• Apex impulse not visible

 PALPATION:

• Apex beat palpable in the right 5th intercostal space just

lateral to right sternal border

AUSCULTATION

• S1 S2 Normal.
• Heart sound are better heard on the right parasternal

area compared to the left side

• No murmurs
• Central nervous system- normal

Case summary

 Positive history: 12 months old immunised child born

to mother of 3rd degree consanguinous marriage with repeated respiratory tract infections

 Positive clinical findings

• Apex beat better felt on right sternal border
• Resonant note on left side >> right
• Decreased breath sounds on left side
• Extensive crepitations through out the lung field

Possiblities – DD ?

Based on the mediastinal shift - DD

1.

Eventration of diaphragm

2.

Diaphragmatic hernia

3.

Cystic adenomatoid formation

4.

Lobar emphysema – TB or Congenital

5.

Kartagener’s syndrome

Complete hemogram

• HB 10.7 gm %
• TC 11,500 cells/cumm

N 47% L 48% E 02% M 03% B 0% PLATELET COUNT 3.34 L/CUMM

• Blood group : B POSITIVE
• BT 2 minutes30 seconds
• CT 4minutes
• RFT normal
• LFT normal
• CRP Negative
• SEROLOGY HIV/HbsAg/VDRL -Non reactive

ABG PH 7.39 PCO2 24.4 PO2 93.7 HCO3 17.7 SO2 96.6% Compensated metabolic acidosis with respiratory alkalosis

Comments...

• Mediastinum shift to

right

• Trachea shifted to right

side

• Left dome of

diaphragm is elevated

• Bowel shadows seen in

left lower chest.

• Dextrocardia
• Normal AV VA
• Normal size cardiac chambers.
• 2 great arteries with normal position
• Intact IVS/IAS
• No PDA /COA
• Normal valves
• No AR/PR/MR/TR
• Good biventricular function
• No pericardial effusion

2D Echo

LEFT DIAPHRAGMATIC EVENTRATION

Provisional diagosis

THANK YOU

Course in the hospital

 On day 1  Child is irritable  No pallor/icterus/cyanosis/oedema

O/E: Vitals: HR-90/MIN RR-28/CMIN SPO2-98%

S/E: RS:BAE +/Equal b/l crepitations present.Left side bowel sounds present Cvs:s1 s2 normal.no murmurs Cns:nad p/a:soft.no organomegaly. Was diagnosed of diaphragmatic eventration and planned for

• surgery. And reffered to department of pediatric surgery

Surgical profile was done. Was started on Taxim,Metrogyl and amikacin PAC advised for ECHO in view of shifted apex.

 On day 2

Child is moderately active No pallor/icterus/cyanosis/oedema

O/E: Vitals: HR-88/MIN RR-36/MIN SPO2-98%

S/E: RS:BAE +/Equal b/l crepitations present.Left side bowel sounds present Cvs:s1 s2 normal.no murmurs Cns:nad p/a:soft.no organomegaly. 2 D ECHO DONE. PAC approval obtained with moderate cardiac risk. Taxim,amikacin and metrogyl continued

 DAY 3

Child is active No distress O/E: Vitals: HR-88/MIN RR-36/MIN SPO2-98%

S/E: RS:BAE +/Equal Left side bowel sounds present CVS:s1 s2 normal.no murmurs CNS:NAD P/A:soft.no organomegaly. Diaphragmatic plication and fixation done. Taxim,Amikacin and Metrogyl continued

DAY 4 Child is active No distress O/E: Vitals: HR-88/MIN RR-36/MIN SPO2-98%

S/E: RS:BAE +/Equal.No added sounds. CVS:S1 S2 normal.no murmurs APEX BEAT PALPABLE ON THE LEFT 5TH INTERCOSTAL SPACE MEDIAL TO MID CLAVICULAR LINE. CNS:NAD P/A:soft.no organomegaly. Taxim,Amikacin and Metrogyl continued.

Diaphragmatic eventeration: